August, 2016

The Nuclear Option

By Michael J. Katin, MD

Campaign 2016 is well under way, with all but one of the major political parties having held their nominating conventions to select their consensus choices for the best persons available to become President of the United States. One thing is certain regarding the issues that will be discussed -- nobody cares what happens to the specialty of Radiation Oncology.

Despite the fact that a "freeze" on technical charges for outpatient radiation therapy facilities was included in the 2015 Patient Access and Medicare Protection Act, there was a conflicting mechanism. The Achieving a Better Life Experience Act had been signed into law on December 19, 2014. Its goal was to produce mechanisms for maximally assisting those with disabilities to participate in our society and to give protection for their care over their lifetimes. An offset for the expense was to accelerate review of relative value units to reduce Medicare and Medicaid spending on these items. Congress set a target foradjustments to be made to misvalued codes in the fee schedule for 2016, 2017, and 2018. The target was one percent for 2016, and will be 0.5 percent for 2017 and 2018.

This may have been a reason that the Proposed Rule for the 2017 Medicare Physician Fee Schedule, released on July 7, included adjustments (i.e., decreases) to the relative value units (RVUs) for specific services resulting from the Misvalued Code Initiative, including treatment devices (CPT 7732, 7733, 7734), special treatment procedure (CPT 77470), and hyperthermia treatment codes (CPT 77600, 77605, 77610, 77615), resulting in a negative one percent impact. and clearly not resulting in a better life experience for radiation oncologists.

Clearly, "misvalued" codes may be considered overvalued by some but undervalued by other, but it seems improbable that the correction always seems to be in the direction of reduction, at least for our codes, but that's the way it goes. In the meantime, the cost of living continues to increase (7.7% in the consumer price index since 2010!) raising the possibility that in the very near future the practice of radiation oncology will cease to exist.

The term "nuclear triad came back into the public mind in December when it was discussed at one of the Republican presidential candidate debates. Whereas most people believe this term refers to the preservation of the United States to launch nuclear weapons by air, sea, and land, this is incorrect. The more important connotation of "nuclear triad is the preservation of the ability to give treatment with external beam therapy, intracavitary and interstitial brachytherapy, and radioisotope therapy. For the past decades, our specialty has been trying to achieve its preservation with the triad of whimpering, begging, and hoping.

It may have come to the time that the last option for survival has to be entertained: nationalization.

In 1917, the railroad system in the United States was not able to keep up with the demands placed upon it by the Great War. It was simply not possible to deliver goods for combatants and for the general public at prices that were allowable and to still keep unions satisfied. To make it even more complicated, legislation in 1916 had required that railroad workers be limited to an eight-hour day. Due to the Sherman antitrust act, the railroad companies could not work together to set adequate rates. On December 26, 1917, President Thomas Woodrow Wilson ordered the nationalization of the railroads and appointed William McAdoo, Secretary of the Treasury (and his son-in-law) as Director General of Railroads. Once the war was over, the railroad were returned to private control, but by 1971 Amtrak was founded as a government-funded agency to run passenger rail service , and in 1974 Conrail was formed to take over multiple bankrupt rail lines. This was accomplished by 1976; Conrail was 85% owned by government and 15% by railroad employees. Conrail was then transformed in 1999 into a number of smaller companies, (with "Conrail" responsible for support services), many of which still rely on government subsidies and favoritism. Amtrak continues to require huge subsidies.

Certainly if it was important enough for our effort in the Great War for railroads to be nationalized, it should be important enough for our effort in the War on Cancer for Radiation Oncology to follow the same track (sorry, couldn't help it).

Similar to the situation with the railroads, radiation oncology cannot continue to operate on the fee schedules with which it's allowed. Physicists, therapists, and physicians will not want to go into this field without some guarantee of stability, let alone adequate compensation. If we are supposed to be concerned about inadequate distribution of services in health care, one need only look at the current heterogeneity in distribution of radiation oncology facilities in the United States as of now, recognizing that this can only worsen. Nationalization would allow distribution of facilities to where they are needed and correct this problem.

If this isn't enough to prompt our elected officials to promote nationalization of Radiation Oncology, there is another factor that should be kept in consideration. Is it reasonable that private citizens should be able to possess spitting cobras? What about flamethrowers and tanks? Well, actually, these are all legal, but would anyone want to consider that radioactivity is too dangerous to be left to the civilian sector? it should be obvious to everyone that the devices used in our field are too hazardous to be made available to the general public. The risk of radioactivity is well known and although regulation by the NRC and other agencies is stringent, there are too many opportunities for accidents to occur. Even worse, there could be deliberate abuse of radiation therapy equipment by nefarious organizations.

These should be reasons enough for the President, Congress, or both to rapidly take action to bring the field of Radiation Oncology under Federal control for our protection and that of our posterity. We hope it will be only a matter of weeks before "Amrad" or "Conrad" will come into existence. As well as provide a Directorship for the son-in-law of the next President.

Emanuel Countdown: Dr. Ezekiel Emanuel's biographies list his birth year as 1957 but, interestingly, do not list a birth date. He has expressed that he does not wish to live past his 75th birthday. Giving him every benefit of the doubt, he will have his 75th birthday no later than December 31, 2032. Including August 1, 2016, this leaves 5,996 days to his goal.